Falls and Fall Prevention _ _____________________________________________________________________
Falls are also the leading cause of traumatic brain injury in patients 65 years of age or older. The extent of head injuries resulting from a fall may be inapparent initially; delayed onset of symptoms and altered mentation may emerge over a few days post-fall [12]. Head injuries involving elderly patients warrant a careful history, taking into account the possibility of secondary hemorrhagic complications resulting from prior anticoagulant and antiplatelet drug usage. Subdural hemato- mas, subarachnoid hemorrhage, skull fractures, and diffuse axonal injury are all potential injuries. Management decisions for head injury should be based on a detailed history of the fall event itself, not just the patient’s initial clinical presentation. Falls from different heights influence whether rapid assessment with head computed tomography (CT) imaging (within certain time frames) is advisable, especially if there are suspected open or depressed skull fractures, focal deficits, vomiting, or history of prior anticoagulants or antiplatelet medications [15]. The presence of any of these features warrants specialized care with neurosurgery consultation to ensure proper treatment and care is provided. FALL INJURY REIMBURSEMENT Reimbursement to hospitals and long-term care facility for costs related to fall injuries is no longer covered by the Centers for Medicare and Medicaid Services (CMS) as of 2008 [16]. However, CMS does reimburse for fall risk assessments and fall prevention programs. Falls were not originally included in the CMS no-pay policy, and the addition of falls to the policy was originally questioned due to lack of supporting evidence of fall prevention efficacy. However, the decision was made to add falls to the no-pay policy in hopes of increasing research efforts to further prevent falls. The CMS has stated, “…we believe these types of injuries and trauma should not occur in the hospital, and we look forward to…identifying research… that will assist hospitals in following the appropriate steps to prevent these conditions from occurring after admission” [17]. Hospitals and clinics also cannot bill the patient for any services related to a “never event,” such as a fall. Any injury costs incurred from a never-event fall (e.g., a humeral fracture) would not be billed to the patient, and the hospital would not receive reimbursement from Medicare regarding these services. They would still, however, receive reimbursement for the treat- ment received related to the original hospitalizing event (e.g., myocardial infarction) [18]. The National Council on Aging (NCOA) notes that although defined fall risk-related services, such as fall risk assessments, in the clinical setting may be lacking, providers should counsel their patients on potential risks of falling [17]. All healthcare providers can boost reimbursement to the hospital by provid- ing and documenting that approximately 50% of a given daily visit was dedicated to education and or counseling on fall risk. These reimbursements for patient education regarding fall risk also apply to Medicare Annual Wellness visits (initial and subsequent) and general offices for follow-ups or illnesses [17].
FALL INJURIES AND REIMBURSEMENT The Joint Commission (TJC) published a sentinel event alert to assist in preventing falls and fall-related injuries in healthcare settings. A sentinel event is “an unexpected occurrence involv- ing death or serious physical or psychological injury, or the risk thereof” [10]. Falls resulting in serious injury or death are among the top 10 sentinel events reported to TJC. Of the 465 falls reported to TJC between 2009 and 2015, 63% resulted in death, while the remaining 37% resulted in injuries only [11]. FALL INJURIES Children between 0 and 5 years of age are learning new skills, such as walking and climbing, which can result in falls from ground level surfaces to several feet, such as off chairs or stairs. Many of these can result in serious injury, including open wounds, fractures, or even severe brain injury [13]. Fractures are a common injury in the older adult population, with approximately 20% sustaining major injuries (e.g., a head injury). Fractures of the hip occur in 1% of all falls in the older adult population [12]. While this is a small percentage, it sig- nificantly increases the risk of morbidity and mortality. After 65 years of age, the observed mortality rate within the first year after a hip fracture repair is 15% to 36%. A prospective cohort study of 728 patients who underwent surgery for hip fractures between 2013 and 2015 found that 121 died within one year post-fracture, a mortality rate of 17% [14]. One-year mortality risk following hip fracture was associated with the development of pressure ulcers, inability to recover pre-fracture ambulation, postoperative anemia, and the development of urosepsis [14]. As noted, other common fracture locations that result from falling are the proximal humerus, pelvis, distal radius, and vertebral bodies. Prosthetic fractures, which occur around joint replacement prostheses, have become more common in the older adult population as well [12]. Many require surgical intervention to repair. Femur fractures are common in the older adult population related to falls. The overall functional decline of older adults post-femur fracture is 50% within the first year [12].
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